Chad M Ruoff, MDInternal Medicine and Sleep

Medicine Fellow9.1.2010

Anatomy of Obstructive Sleep Apnea Weight Loss Oral Appliances

• Mandibular Advancement Device• Tongue Advancement Device

External Nasal Dilator Strips (Breathe Right Strips) Wedge Pillow Positioning Provent Surgery Pillar Procedure CPAP TAP Device

• Using an oral appliance with CPAP Maxillary Expansion Future

• Nerve Stimulator

• AHI

• RDI

• Oxygen desaturation

A 10 % weight loss may lead to about a 30% reduction in the AHI (Young et al)

Neck circumference is an important predictor of sleep apnea.

Men 17 “Women 16 ”

Mild to moderate sleep apnea• In one case series, 50 to 80 % of patients

have a reduction in AHI by at least 50% Severe OSA

• Success rates range between 14 and 61% Success rate defined as AHI less than 10 or a 50% reduction

Protrudes the mandible forward from 6 to 10 mm.

They also might open the mouth slightly

Predictors for Treatment Outcome• Younger age• Lower BMI• Smaller neck circumference• Positional OSA• Increased amout of protrusion by appliance

Better tolerated than CPAP• 76 – 90% patients report regular use in

recent studies.

Consider an oral appliance once fail a CPAP trial

Adjustable appliances are better than fixed appliances

An oral appliance is not as effective as CPAP

Common side effects include mucosal drynesss, tooth discomfort, excessive salivation, and jaw pain

Long term use associated with small orthodontic changes

Consider in patient with poor dentition, relatively large tongue, or a poor protrusive range

Side effects include tongue soreness and excessive salivation

Not as effective as a MandibularRepositioning device

Mechanically pull the lateral nasal vestibule walls outward

Increases nasal cross-sectional area

FDA approved for temporary relief from transient causes of breathing difficulties resulting from structural abnormalities and/or transient causes of nasal congestion associated with reduced airflow

May reduce maximum snoring intensity.

Worsening of disease in some patients has been observed.

Not indicated for the treatment of sleep apnea

Limited data suggestthat these devices improvenasal resistance or airflow

Available studies indicatethat snoring intensity may be reduced

Sleep, Vol 26, No. 5, 2003

There is currently insufficient evidence to recommend any systemic pharmacological treatment for OSA.• In one study, topical fluticasone in patients

withcoexistent rhinitis and OSA reduced apnea

• Paroxetine, physostigmine, mirtazipine and acetazolamide have been shown to reduce the frequency of apneas, but the symptomatic response remains uncertain.

We need more robust clinical trials. Drug therapy for obstructive sleep apnoea in adults (Review). The Cochrane Collaboration. 2009

Minimizes the effects of gravity on the airway and may decrease reflux.

Minimizes the effects of gravity on the airway and may decrease reflux

Use a T-shirt with a pocket sewn on the back with a tennis ball or golf ball in prevent supine sleep

The Zzoma Positional Sleeper

In a recent trial, positional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA with similar effects on sleep quality and nocturnal oxygenation.

The non-supine AHI had to be less than 5 events per hour.

Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea. J Clin Sleep Med. 2010 Jun 15;6(3):238-43.

Uses nasal expiratory flow resistance to create positive airway pressures to prevent collapse of the airway

Funded studies have shown reductions in AHI from 27 to 14

The overall response rate, defined as a 50% or more reduction in the AHI for this novel device during the initial three treatment nights was 59%. It dropped to 41% at the end of 30 days.

Prior to CPAP in 1981, this was the only treatment option available for sleep apnea.

Address the three regions of potential collapse in sleep apnea:• Nose: Septum, Turbinates, and Nasal Valves• Palate: Tonsils and Uvula• Base of tongue: Tongue base

There is a lack of sound evidence documenting the benefits of surgery.

We need more robust clinical trials.

We are really getting away from recommending this as a first line treatment option. However, it is still a common recommendation for the pediatric population.

Success rate of about 40%. However, this procedure is not routinely recommended.

Side effects include dificulty swallowing, globus sensation in the throat, and voice changes

The cure or responder rate with proper candidate selection: About 80% (65 to 100%).

Success typically defined as a 50% reduction or RDI < 20 and oxygen saturation > 90%

This is typically not considered a primary therapy but rather an adjunctive procedure.

Responders range from 25 to 70%.

Consider this therapy if experiencing significant nasal congestion with your CPAP or daytime symptoms of congestion

• In spite of heated humidification, nasal saline washes, and nasal steroids

In one small trial after 8 weeks of procedure, 21/22 patients had about a 60% reduction in severity and frequency of nasal obstruction

Phase I: Address the nose, pharygneal space, and address hypopharynx area (e.g Laser, TCRF, GAHMS)

Phase 2: SkeletalMidface advancement (i.e. MMO or Bimax)

Three small 18mm polyethylene terephthalate fibers permanently inserted within the muscular layer of the soft palate and hard palate junction

In one trial it produced bed partner snoring satisfaction in 40 % - 60% of cases

Complications include high risk of implant extrusion and poor placement causing discomfort

We do not recommend this as a treatment option.

This therapy combines an oral appliance with the CPAP.

No published data to my knowledge

Consider this in a child with sleep apnea

Decreases nasal resistance More room for the tongue to stay in a forward position

Nerve stimulation• Hypoglossal nerve stimulation

• Nerve manipulation is already underway in refractory seizures and in severe movement disorders

CPAP Oral Appliance Weight loss with proper eating habits

and consistent exercise Foam wedge pillow Positioning Surgery

Questions?